Urinary stone ER note 편집하기

{| class="wikitable"
|· '''C.C''': onset, recent onset, pain nature, radiation, attack Hx. 

· '''P.I''': 환자 평소 (과거력 있던 자, 건강했던 자)로 부터 (갑자기, 서서히) develop된 (어느 부위) pain을 주소로 본원 ER내원. 

· '''PMHx''': Hepatitis/HTN/DM/Tbc ( /// ) OP Hx Stone Hx ( ) 

· '''ROS''': A/N/V/C/D ( //// ), F/C ( / ) 

· urinary Sx: frequency (1번/ 시간), nocturia ( 번/1 night) 

· dysuria (-/+), tenesmus (-/+), hematuria (-/+), weak stream (-/+), decreased urine volume (-/+) 그외 특이 Sx: 

· '''P/Ex''': Vital ('''fever'''), Mental, General condition Head & Neck: anemic, icteric, soft neck Chest: Heart, lung sound 

Abdomen: Bowel Sound, abd scar, 

'''abd T/RT''' ( /) '''appendicitis 와의 감별에 유의, CVAT''' ( /) 

Extrimities: pitting edema, grossly free. 

· '''ER Order''': 

1. fluid 30GTT (환자 pain심하면 spamon 2@ 섞어 주세요.) 

2. routine Lab. (CBC, B/Cr, elctrolyte, U/A with microscopy ) 

3. routine X-ray (Chest PA, KUB, erect Abd.)

4. prn Lab. (if fever>37.8 → urine GS, urine culture, urine AFB) 

5. prn inj. (if pain → Tarasyn 1@/#od IM). If, pregnant women, Demerol 25mg/IM 

· '''Lab'''.: 

1. X-ray: '''KUB- level 에서 stone 보임.''' 

CXR- pleural effusion (-/+) 

2. urine study: U/A with microscopy ( '''RBC''': ,WBC: ) 

3. serum study: BUN/'''Cr''', CBC 

· '''Plan & recommend''' 

1. '''non-enhanced CT with KUB''' (병원마다 다름) 

2. Discharge medication 필요시 항생제 항진경제, 진통제는 섞어줄지, prn으로 할 지 결정
|}